Recent lessons in the meaning of Community

What does it mean to be part of a community?

This past week, two widely reported events should cause us to consider the very nature and meaning of “community”.

The first such event, of course, is the crash of Ukraine International Airlines Flight 752 in which all 176 people on board perished, including a large number of Canadian citizens and others with close ties to Canada. Because many were involved in educational programs of various types, the Canadian university community was hard hit. The response was immediate, unified and sincere. Within my own community of undergraduate deans, there was a flurry of emails and texts expressing concern and offering support. Members of the medical student community came forward expressing concern for friends and colleagues across the country. Although some schools were more directly affected than others, all shared in the sense of loss.

Particularly revealing is that the concern and response to this disaster cut through any issues of cultural or religious background. The victims were remembered not as members of any particular group, but as people we came know as individuals, with personal traits and aspirations with which we could all identify. Obvious differences simply didn’t matter.

Later that same week, we learned of the death of Neil Peart, a member of the legendary Canadian rock band Rush and arguably one of the greatest drummers of all time. Although a member of my generation, Mr. Peart’s appeal was not confined to any age group. In fact, it was my children who drew my attention to his virtuosity and expansive lyrics. When news of his death was announced, tributes appeared on social media from diverse sources – everyone from lead singer and drummer of the Foo Fighters Dave Grohl to Prime Minister Justin Trudeau. Beyond his great talent, Peart was an iconoclast who always engaged life in his own way with an authenticity and integrity that inspired a community of admirers, young and old. From an interview with Rolling Stone in 2015,  “It’s about being your own hero. I set out to never betray the values that a 16-year-old had, to never sell out, to never bow to the man. A compromise is what I can never accept.” This spirit was a rallying call that held an ageless appeal.

The very word “community” has meaning beyond its reference to a group of people living in the same location. A deeper meaning, the one that came so vividly to light in the events of this past week is “a feeling of fellowship with others, as a result of sharing common attitudes, interests, and goals.”

Tragic and sad events are an inevitable aspect of the human condition. Physicians and all health providers accept as a professional responsibility the support and assistance of individual patients and their families through such events. We are prepared and trained to do so. But when tragedy impacts the communities in which we live, we share in the loss and struggle together to find meaning.

These two recent events teach us that the concept of community transcends barriers of culture and age and helps us find some such meaning.

They remind us that community is about the forces that bind us in common interest and intent. Community provides unconditional support and strength.

Community occurs when we choose to focus on what we share rather than what separates us.

In the end, community is a choice.

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Christmas wishes for our Medical Students – by the year.

Through late November and December, as darkness consumes more and more of our days, the School of Medicine Building seems to get brighter. From the outside, it seems lit for the season. Inside, the rooms and study spaces are fully occupied. It’s that time of year, of course, when first and second years are preparing for examinations. There’s also a sense of anticipation. Anticipation for the end of exams, to be sure, but also for what’s to come.

Indeed, all the world seems in anticipation as we approach the winter solstice, that moment in time when the combination of orbit and axis of the earth take us farthest from the sun and we receive the least daylight. But after December 22, the light starts to slowly return.

In the Christian tradition, this is the season of Advent, a time of expectant waiting and preparation. In the Jewish culture, Hanukkah is celebrated, known as the “Festival of Lights”, commemorating the rededication of the Second Temple. Many cultures mark the time of year in various ways, both religious and secular. For all, it’s a time that we instinctively wish to return to the familiar and comforting warmth of home. It’s a time to retreat, refresh, renew.

In the spirit of the season, I offer Christmas wishes for our students:

For first years, increasing comfort with their transition to the profession, with learning for the sake of learning, and for future patients.

For second years, deepening fascination with clinical medicine and comfort with multiple career options.

For third years, increasing confidence in the clinical environment and a growing sense of their own, individual roles within it.

For our fourth years, first choice discipline, first choice program, first time.

For all, a restful, restorative and safe break, and best wishes for the new year all it will bring.

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Pivotal Court Battle Raging in British Columbia: Should preferential health care be available to those who can afford it?

A rather fierce and highly significant battle is raging in the courts of British Columbia. At stake is the future of private payer medical care in Canada. Many feel that what’s really at stake is the future of universal health care in Canada. Pragmatically, the issue boils down to whether decisions about when and how patients get care should be determined solely by need, or whether those with resources should be able to access alternative routes, and whether physicians should be allowed to provide those alternatives.

The Globe and Mail

At the centre of all this is Dr. Brian Day, an orthopedic surgeon and former president of the Canadian Medical Association, who is the Medical Director and Chief Executive Officer of the Cambie Surgery Centre in Vancouver, which opened in 1996 and has been offering and providing services to insured and privately paying patients. It has been doing so despite (in the case of the privately paying patients) being in violation of the B.C. Medicare Protection Act, which prohibits physicians from working in public and private systems at the same time or, more precisely, from charging patients for publicly covered services. It also prohibits the sale of private insurance for medically necessary hospital and physician care (insurance is permitted for care not covered by the public system). It seems that for the past 20+ years the government has either made only half-hearted attempts to enforce the law, or simply “looked the other way”.

It appears that current governments are much more committed to enforce the letter of the law, and Dr. Day has mounted a challenge based on the Charter of Rights and Freedoms. He and his lawyers argue that the Charter-provided right to pursue life, liberty and personal security extends to the right to pay for care when someone feels the public system doesn’t provide it to their satisfaction. They make it clear that they are not opposed to medicare or interested in dismantling it. They point to effective blended public/private provision in many countries, claim no evidence of harm and opine that it may actually benefit the public system by “off-loading” some patients. In their closing arguments (as reported in the Globe and Mail November 13, 2019) his lawyers claim:

“Allowing British Columbians to obtain private medically necessary services would not result in any harm to either the accessibility or viability of the public health-care system, as demonstrated by the experience over the past 20 years in British Columbia, when the prohibitions on access to diagnostic and surgical services were not enforced.”

“Further, the government cannot justify imposing severe mental and physician harm on some residents on the basis of an ideological commitment to perfect equality in access to treatment, which is neither created by the legislation in question nor obtained in practice.”

There is, as one might imagine, considerable opinion to the contrary. It comes from groups such as the BC Health Coalition, Canadian Doctors for Medicare, and many individual physicians and patients who have put forward rather strongly worded counter-arguments. They feel the presence of condoned private care in BC will set precedents for the rest of Canada and undermine the principle of universal care by siphoning physicians, nurses, therapists and technicians to potentially more lucrative opportunities in the private sector. In the case of physicians, they feel this is a betrayal of the publicly financed education they’ve been provided.

The case, which has been ongoing for several months, is now in the hands of BC Supreme Court Justice John Steeves who must decide whether the BC Medicare Protection Act indeed violates Canada’s Charter of Rights and Freedom.

This impending decision, indeed this very issue, is highly significant not only for those in the medical community, but for every Canadian. Medicare has taken on a special place in Canadian cultural identity. It has become a defining element of the national character, and a source of pride of all citizens. If there are any “sacred cows” in Canadian politics, Medicare would certainly be one. But its introduction and maintenance have been far from easy.

Chief among the challenges has been the division of federal and provincial responsibility and, therefore, funding. The British North America Act of 1867 establishes among the exclusive powers of provincial legislatures,

“the Establishment, Maintenance, and Management of Hospitals, Asylums, Charities and Eleemosynary Institutions in and for the Province, other than Marine Hospitals.”

The provision of so-called comprehensive Medicare began in a piecemeal fashion in the 1940s, but gained momentum in the 1960s, largely through the efforts of the then premier of Saskatchewan, Tommy Douglas. A key step along the way was the passage in Saskatchewan in 1961 of the Saskatchewan Medical Care Insurance Act which basically guaranteed health coverage to all citizens. That included physician fees, and so Section 18 of the act includes the following:

“No physician or other person who provides an insured service to a beneficiary shall demand or accept payment for that service.”

Thus, direct physician billing to patients was essentially outlawed. Mr. Douglas turned his attention to the federal scene as he became leader of the New Democratic Party and his efforts were instrumental in the passage of the Medical Care Act of 1966, which obligated the federal government to provide half the provincial and territorial costs for medical services provided for a doctor outside hospitals. By 1972, all the provinces and territories had some form of plan to reimburse for physician services. The Canada Health Act of 1984 states in its preamble the primary objective:

to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

Like British Columbia, the provinces have developed legislation designed to ensure universal and funded provision of care. In Ontario the Health Care Accessibility Act of 1986 essentially outlawed billing of patients outside the provincial insurance plan, and has been subsequently reinforced by versions of the Commitment to Future of Medicare Act.

And so, what are the considerations that are likely going through Justice Steeves mind as he ponders this momentous decision?It seems obvious that government-supported medicare has the considerable advantage of ensuring a standard level of care to all patients regardless of their economic means, and of ensuring physicians are compensated.

  • It seems obvious that government-supported medicare has considerable advantage of ensuring a standard level of care to all patients regardless of their economic means, and of ensuring physicians are compensated for their services.
  • There seems little doubt that a decision in favour of privately funded clinics will give rise to many similar operations throughout the country, particularly in large urban centres.
  • The risk of an exodus of talent from the public to private system seems real.
  • There are, indeed, many examples from other countries supporting the concept that the two systems can co-exist. However, it would seem that’s only true if there is some provision for mandatory participation of physicians in the public system.
  • It’s becoming apparent that the ability to fully fund “universal” care solely through the public coffer is not sustainable. We’re seeing examples of this almost daily. Hospitals, despite best efforts, are going beyond budgets to provide care, and there are clearly insufficient options for the care of needy outpatients.   Not only is the population getting larger and older, but highly effective (and very costly) therapies have emerged and are continuing to emerge for the treatment of conditions that previously had no options other than palliation. Wait times are certainly lengthening, and “hallway medicine” becoming the norm.
  • There’s no question that for many procedures with very long wait times, such as hip and knee surgeries, the critical bottleneck is not the availability of qualified physicians, but rather access to hospitals and operating rooms which could, theoretically, be at least partially addressed by providing privately funded facilities.
  • What effect a private system would have on public system wait times is, we must honestly admit, unknown and can’t be reliably projected. It will depend, to a large extent how many private facilities emerge, what services are provided, and what constraints are put on the providers.  

A critical and rather sobering consideration in all this is that the success or failure of any blended private/public model may hinge on the willingness of physicians to continue to provide care to patients regardless of ability to pay. It will test and expose their motivations and priorities. It will test their allegiance to the principles the profession has always espoused, expressed in the words of the World Health Association Oath, and taken in by most medical students, including those at Queen’s:

“I will not permit considerations of religion, nationality, race, gender, politics, socioeconomic standing, or sexual orientation to intervene between my duty and my patient”

Those who so vehemently oppose privately funded care apparently believe physicians will abandon these principles in favour of personal income. I believe, and hope, that they’re wrong. Whatever the outcome of this court case, I choose to believe that physicians will continue to use their training and skills as they were intended, for the benefit of all.   

The issue of whether well-resourced citizens have a charter-assured right to more expeditious health care, and whether that privilege impinges on the rights of the less-well-resourced, seems beyond objective analysis and, in my view, is best left in the hands of a fair- minded and impartial judiciary. In the end, our system for deciding such dilemmas has been well thought out, and is worthy of our trust.

Godspeed, Justice Steeves.

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Our Aesculapian Society – Contributing to a Long Tradition of Collaboration and Service

The medical student society at Queen’s dates back to 1872 and is named in honor of Aesculepius, the mythological Greek figure considered the god of medicine. In fact, Aesculepius had five daughters each of whom represented some aspect of medicine considered essential to health. Hygieia was the goddess of cleanliness, Iaso the goddess of recuperation from illness, Aceso the goddess of the healing process, Aegle the goddess of good health and Panacea the goddess of remedies. The Greeks, it seems, knew something about social determinants of health and the value of personal wellness.

I’m very pleased to see that our current students are keeping the long tradition alive and contributing to the health of their fellow students and the learning community. The article that follows from our current and immediate past Aesculapian Society presidents (Danny Jomaa and Rae Woodhouse) describes their recent successful efforts to establish a fitness facility within the hospital. In doing do, they got great support from Mr. Chris Gillies and Mr. Adam Bondy of KGH.

Congratulations to Danny, Rae and all their AS colleagues. Aesculepius would be proud. I know we are.

Anthony Sanfilippo

Associate Dean

Undergraduate Medical Education

The Aesculapian Society is thrilled to announce the opening of a dedicated gym for medical students and residents in Kingston General Hospital (KGH). This project has been a year in the making and has been a collaborative effort between the Aesculapian Society, the Professional Association of Residents of Ontario (PARO), and the KGH administration. In early 2018, the Aesculapian Society set out to utilize a pool of funding to benefit current and future medical students. From student consultation, two projects were selected to be pursued further. The first was a revitalization of the kitchenette in the School of Medicine Building and the second was the creation of a gym in KGH. The latter was selected due to its focus on student wellbeing – a widely recognized priority at the School of Medicine. This idea stemmed from an Aesculapian Society Initiatives Grant proposal that was originally submitted in 2017 by Dr. Matthew McIntosh (MEDS 2018). The first step was finding a suitable space for the creation of this gym. In collaboration with Chris Gilles (KGH Director of Medical Affairs) and the Queen’s PARO Executive team, an under-utilized lounge in KGH was selected to be the new space for the medical student and resident gym. The timing could not be more serendipitous; the hospital’s insurance policy had recently approved the creation of a gym, which had been a long-time priority for physicians and residents alike. The newly completed gym, located on Connell 6, includes a range of cardio equipment, strength equipment, and fitness accessories.

The success of this project was possible because of the many individuals that contributed to each step of the gym’s creation. We would like to especially thank Chris Gillies and Adam Bondy (Project Coordinator) from KGH for championing the implementation and set-up of this project. We would also like to thank PARO for their generous provision of space and collaboration. Finally, this project would not have been realized without the dedication and enthusiasm of the Aesculapian Society Councils of 2018-2019 and 2019-2020. We would like to extend our gratitude to the students that supported this initiative by providing their input, ideas, and encouragement.

The Aesculapian Society recognizes that students have a variety of wellness needs and this gym primarily supports students’ physical wellness. We look forward to collaborating with student body and the UGME to expand upon, and create initiatives that support other aspects of student wellbeing. We look forward to seeing the lasting impact that this project will have on Queen’s medical students and residents for years to come. The Aesculapian Society encourages students and residents to provide feedback on how the gym can be improved to better serve our community’s needs.

Danny Jomaa, President

Rae Woodhouse, Past-President

Aesculapian Society 2019-2020

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An election no one won. Is it finally time for electoral reform?

We’ve recently come through a federal election where there appear to have been very few winners.

Certainly not the Liberal party, who saw their seats in the House reduced and must now attempt to govern with no majority and little support from the three prairie provinces.

Certainly not the Conservatives who failed to capitalize on what many saw as a golden opportunity to unseat the incumbent government.

Certainly not the NDP who saw their number of seats reduced drastically despite having a charismatic and articulate leader.

Certainly not the fledgling People’s Party of Canada, who won no seats, not even the one contested by their leader.

Probably not the Green party, although they did gain a seat outside British Columbia.

In fact, the only party that could be assessed as having emerged with a positive result is the Bloc Quebecois, whose main goal is to protect the interests of a single cultural group within a single province, even if it means breaking up the country.

Perhaps the most disappointing aspect of this election is the voter turnout or, perhaps more accurately stated, non-turnout. Fully 34% (that’s one in three!) of eligible Canadian voters decided to take a pass on this election. This is not exactly new. Voter turnout in the 43 Canadian federal elections that have been held since confederation has averaged 70.3%, ranging from highs of 79% in the early 1960s to a low of 58.8% in 2008. In that light, our current results might not seem too disappointing, if not that they appear to be part of a concerning downward trend which seemed to begin in the late 1980s.

And so, we must ask, what is it that keeps folks from exercising their right to influence our country’s government in the only way that will be available to most of them? It’s certainly not any lack of significant contemporary issues or a sense of satisfaction with the conduct of our current government. It’s certainly not that voting isn’t as easy as possible, including widespread availability of advanced polls. So what is it?

That very question was the subject of a 1989 Royal Commission on Electoral Reform. The authors identified a number of factors that prevent people from voting. Many are very practical, logistic issues such as illness, being away from home at the time, or just being too busy. However, a leading cause that emerged was simply labeled simply as “wasn’t interested”.  A leading author of the document, Jon H. Pammett, described what he termed “administrative disenfranchisement”, meaning that the procedures involved in the voting process inhibit participation.

The results of the recent election highlight another cause of voter discontent that has been the focus of increasing attention and political lobbying over the past few years. Our parliamentary, party-based system combined with the marked variations in population density that exist in our country gives rise to a disturbing disconnect between the popular vote and final outcome.

For example, the Liberal party’s 33.1% of the popular vote translated into 46.4% (157) of the seats in the House of Commons. The Conservative party, which actually received a higher percentage of the popular vote (34.4%), won 26 fewer seats (121 or 35.8% of the available seats). The NDP’s 15.9% of the vote, in a proportional sense, should have earned them 54 seats, but they’ll go into the next parliament with only 24 seats, whereas the Bloc Quebecois’ 7.7% of the vote yielded 32 seats in voter rich Quebec. Perhaps the most egregious injustice relates to the Green Party. In an evenly distributed system their 6.5% share would translate into 22 seats, rather than the 3 seats they won. Even the fledgling People’s Party, which won no seats at all, can cry foul given that their 1.6% of the voting share would proportionately correspond to 5 seats.

Regardless of your political affiliation or preferences, it’s easy to understand why so many people are finding this disturbing, and why voters, particularly those is less populated parts of the country, are left feeling frustrated, discouraged and the sense that their individual votes are devalued or even meaningless. Adding to all this electoral confusion is the persisting problem that, in a parliamentary system, the voters don’t directly elect the highest political office in the country. This brings, with every election, the perennial and vexing conundrum of whether to vote for the local candidate on the basis of their personal capabilities, or the party they represent. In a democratic society, should voters be forced to make that choice? Might that be contributing to their frustration and apathy?

Changing such a deeply established process will, of course, not be easy. It would require determined action from the very politicians who have benefited from the status quo. Nonetheless, it seems that the time has come for at least an open debate on the issue. Those with the courage to take this on might be worth voting for!

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Plastic Snow? It’s official…we’ve gone too far. It’s time to act.

Meet my grand-nephew, Tristan. He’s been visiting from Nova Scotia with his parents. He’s 7 months old and, this past week, is starting to crawl and had his first haircut. He’s also the inspiration for this week’s blog. But more about him later…

We’ve grown accustomed to reading reports of grave environmental threats. For most of us, there is as yet little direct impact and we’re able to regard these concerns in the abstract. With time and repetition, we develop something akin to resigned indifference, participating in recycling efforts with reluctant acquiesce. 

I’ve recently come across some information that should cause us all to pause, consider what’s happening to our environment and our own, personal culpability.

In a 2017 article appearing in Science Advances (Geyer, Jambeck, Law, Sci. Adv. 2017; 3: e1700782), researchers from three American universities and institutions with expertise in environmental issues reported on the “Production, use and fate of all plastics ever made.” Their conclusions are, to say the least, rather sobering. To summarize:

  • 8.3 billion metric tons of plastics have been manufactured to date
  • Of that, 6.3 billion metric tons remain as plastic waste accumulated in landfills.
  • Only 9% has been recycled, 12% incinerated
  • If current trends continue, it’s projected that 12 billion metric tons of plastic waste will find its way either into landfills or the natural environment by 2050.

The projections they have developed are rather frightening as portrayed in this graph from their paper:

Plastic products are, of course, designed to be durable. Basically, they don’t go away, and this article makes it clear that our current recycling efforts aren’t nearly adequate.

To put this into more comprehensible terms, researchers at the Rochester Institute of Technology have recently estimated that 22 million pounds of plastic debris enter the Great Lakes every year. Our own Lake Ontario, which we Kingstonians walk or drive by every day, receives the equivalent of 28 Olympic size swimming pools of plastic bottles each year, and they don’t go away.

(https://phys.org/news/2016-12-metric-tons-plasticgreat-lakes.html)

If that’s not enough to get our attention, consider work recently published by Dr. Melanie Bergmann and her colleagues at the Alfred Wegener Institute in Germany, also in Science Advances (Bergmann et al, Sci. Adv. 2019; 5: eaax1157).  

They point out that plastics don’t dissolve harmlessly into the environment, but under a number of physical stresses (mechanical abrasion provided by waves, for example, or temperature fluctuations) they can be broken into much smaller particles, termed microplastic, measuring less than 5mm. It’s already been well established that these can be found not only near large urban centres, but also in northerly ocean seabeds and coastal sediment. What hasn’t been clear is how they get there. It’s been postulated that microplastics have the capacity to be carried into the atmosphere and find their way to points very remote from their original dumping grounds. The capacity to become airborne not only explains this wide distribution, but potentially threatens human and animal exposure through inhalation.

To test this possibility, they set out to look for microplastics associated with snow because, in the words of the authors “snow is a scavenger for diverse impurities, and acts as a filter on the ground by dry deposition”.  Using techniques far beyond my understanding, they measured levels of various microplastics in snow samples gathered from ice floes and islands in the Arctic, and compared with samples from urban centres in northern Europe and from the Alps.

They found plastic microparticles in snow gathered from all sites. Although there was much more from the cities, there were detectable levels in the snow scooped up from ice floes drifting in the Fram Strait and on Svalbard Island in the far north, far from any population centre, in quantities they described as “substantial for a secluded location”.

They conclude that snow has the ability to bind these airborne particles and carry them back to earth, a process they term “scavenging”. They conjecture that this process can allow for microparticles to find their way into water supplies and food chains. They even recommend that large northern cities give thought to where they deposit collected snow in the winter, to avoid contamination of water sources.

If we needed any further convincing about the need to curb use of plastics, I think it’s now available. Particles from the bottles or straws that we use to conveniently transport beverages to quench our thirst are finding their ways to the most remote, unpopulated regions of our planet, previously considered pristine. The ice and snow, always symbols of purity, are now tainted. Children who will soon be running outdoors to frolic in the first winter snowfall may be putting themselves at risk.

Getting back to young Tristan, what sort of world are we shaping for he and his peers? What can we do, given the virtually ubiquitous presence of plastics in our society? Personal action, to be sure. We should make all efforts to minimize our own usage and maximize recycling efforts. But also political awareness, particularly in this election year. No political leader or party that fails to understand the true impact of environmental contamination is worthy of our support. We should expect well-articulated platforms that address both local and international approaches. We have a responsibility to be vigilant, not only for ourselves, but also for those not yet able to speak for themselves but have so much at stake. 

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Welcoming Meds 2023

As the days get shorter and leaves begin to fall we reluctantly acknowledge that summer is giving way to autumn. In any university community another sure sign is the return of students, heralding the beginning of another academic cycle. At Queen’s School of Medicine, this past week marked the 165th time a group of young people arrived to begin their careers.

Photo by Garrett Elliot

This year’s group consists of 108 students, drawn from an applicant pool of over 5500. They come all regions of our country and backgrounds. One hundred and eight individual paths leading to a common goal that they will now share for the next four years. Eighty-four of them have completed undergraduate degrees, 30 Masters degrees, and five PhDs

They hail from no fewer than 53 communities spanning the breadth and width of Canada. The universities they have attended and degree programs are listed below:

   
   

 An academically diverse and very qualified group, to be sure.  Last week, they undertook a variety of orientation activities organized by both faculty and their upper year colleagues. 

On their first day, They were welcomed by Dr. Richard Reznick who challenged them to be restless in the pursuit of their goals and the betterment of our patients and society.

They were called upon to demonstrate commitment to their studies, their profession and their future patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  They were welcomed by Mr. Danny Jomma, Asesculapian Society President, who spoke on behalf of their upper year colleagues, and Dr. Rachel Rooney provided them an introduction to fundamental concepts of medical professionalism. 

Over the course of the week, they met curricular leaders, including Drs. Andrea Guerin, Lindsey Patterson and Laura Milne.  They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Martin Ten Hove, Jason Franklin, Mike McMullen, Josh Lakoff, Erin Beattie, Lauren Badalato and Susan MacDonald who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us.  They met members of our superb administrative and educational support teams led by Jacqueline Findlay, Jennifer Saunders, Theresa Suart, Eleni Katsoulas, Amanda Consack, and first year Curricular Coordinator Jane Gordon

They attended an excellent session on inclusion and challenges within the learning environment, organized by third year student Alisha Kapur and student members of the diversity panel, supported by Drs. Mala Joneja and Renee Fitzpatrick. The presentation included dialogue from a panel of upper year students (Leah Allen, Palika Kohli, Vivesh Patel and Naveen Sivaranjan) who provided candid and very useful insights to their first year colleagues. That was followed by a thought-provoking and challenging presentation by Stephanie Simpson University Advisor on Equity and Human Rights.

Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students.  This year, Drs. Erin Beattie, Wiley Chung, Bob Connelly, Jackie Duffin, Michelle Gibson, Brigid Nee, Siddhartha Srivastava and David Walker were selected for this honour.

On Friday, the practical aspects of curriculum, expectations of conduct and promotions were explained by Drs. Michelle Gibson, Cherie Jones and Lindsey Patterson.

Their Meds 2021 upper year colleagues welcomed them with a number of formal and not-so-formal events.  These included sessions intended to promote an inclusive learning environment, as well as orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.

For all these arrangements, skillfully coordinated, I’m very grateful to Rebecca Jozsa, our Admissions Officer and Admissions Assistant Rachel Bauder.  

I invite you to join me in welcoming these new members of our school and medical community. I leave you (and they) with the Bob Dylan lyrics that Dr. Reznick shared with the class this past week:

May your heart always be joyful
May your song always be sung
And may you stay forever young

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Changes

Dedication and organizational effectiveness are key leadership qualities, but do not always combine in the same individual. When they do, the result is a person who is a hugely valuable resource to the organization they serve. At Queen’s, we’ve been very fortunate (some would say “blessed”) to have many such dedicated and effective people involved in medical education. One would hope such people could continue in their roles indefinitely. However, from time to time, change is necessary. In the Undergraduate program, a number of changes are occurring at this time, partly because of life transitions, but also in order to ensure that we continue to refresh perspectives, allow gifted people the opportunity to learn multiple roles, and position ourselves optimally for our next major accreditation review about three years from now. I would like to use this article to announce a number of those changes.

Assistant Deans

Dr. Hugh MacDonald, Dr. Renee Fitzpatrick, Dr. Cherie Jones, and Dr. Michelle Gibson

Although these have already announced, I thought it appropriate to re-iterate that, over the past year, we have appointed four Assistant Deans with responsibility for key components of the UG program. In the cases of Dr. Hugh MacDonald, Assistant Dean UG Admissions, and Dr. Renee Fitzpatrick, Assistant Dean Student Affairs, these appointments recognized the increased scope of responsibility that had evolved in positions previously designated as committee chairs or directorships. In the case of Dr. Cherie Jones, Assistant Dean Academic Affairs and Programmatic Quality Assurance, and Dr. Michelle Gibson, Assistant Dean Curriculum, these are de novo positions addressing key components of our program that were previously undertaken either solely by the Associate Dean or committee chairs. These consolidated responsibilities will provide focused attention and responsibility for critical aspects of program delivery.

Clerkship

Dr. Andrea Guerin, Dr. Susan Moffatt, Dr. Heather Murray

The clinical clerkship, spanning the final two years of medical school, consists of two components. The Clinical rotations consist of discipline-based rotations and/or integrated, longitudinal community-based rotations, and Electives. For the past several years, this aspect of the clerkship has been very capably directed by Dr. Andrea Winthrop. During that time, it has grown and evolved steadily, notably with expanded regional experiences and integration of EPAs as the basis for assessment. Dr. Winthrop is now moving to take on a new, needed role in our curriculum (see below). Dr. Andrea Guerin, who has been directing Year 2 of our curriculum, will be taking on the Clerkship directorship. 

The Clerkship Curriculum consists of three blocks interspersed through the final two years where the students re-assemble as a class and undertake learning in Clerkship Preparation, Complex Presentations, and Preparation for Residency. They have been very skillfully and thoughtfully developed, planned and directed by Dr. Susan Moffatt, and have become very highly valued by our students. Over the next year, directorship of the Clerkship Curriculum will be transitioning to Dr. Heather Murray who, as Dr. Moffatt, is a highly accomplished and recognized educator. (Dr. Murray won the Chancellor Charles A. Baillie Award from the Queen’s University Centre for Teaching and Learning this year).

Pre-Clerkship Director

Dr. Lindsey Patterson

In the early years of our curricular reform, the extensive structural and content change required separate directorship of Years 1 and 2. As our curriculum becomes more established, and our curricular coordinators become more familiar with roles and operational issues, we have arrived to a point that the roles can be combined into that of a Pre-Clerkship Director, which is consistent with practice at most other medical schools. I’m very pleased to announce that Dr. Lindsey Patterson, current Year 1 Director, will be taking on this expanded responsibility.

Intrinsic Role Director

Dr. Andrea Winthrop

Our last major curricular revision introduced explicit objectives and teaching regarding the so-called “non-Medical Expert competencies”, and development of committee and chair to oversee the activity of individuals charged with the development of each role (Competency Leads). Dr. Ruth Wilson initially chaired that group and was instrumental in the development of those aspects of our curriculum. When Dr. Wilson stepped away from that role, we elected to allow the Competency Leads to function independently. It’s now clear that the importance and complexity of these roles, together with the administrative requirements to ensure appropriate curricular design and delivery, necessitate centralized support. We are therefore re-establishing the role of Intrinsic Role Director, and Dr. Andrea Winthrop will be taking this on. Dr. Winthrop’s extensive knowledge and experience with our curriculum, together with excellent organization skills, make her an excellent choice for this key role 

Term 3 Clinical Skills

Dr. Laura Milne, Dr. Basia Farnell, and Dr. Meg Gemmill

Dr. Laura Milne directs our Clinical Skills program, which spans all four terms of the pre-clerkship, and is consistently very highly reviewed by our students and seen as a highlight or our curriculum. For the past few years, Dr. Basia Farnell been directing the Term 3 component of Clinical Skills, and has provided energy and creativity in revising the format and curricular content. As Dr. Farnell moves on to other challenges, Dr. Meg Gemmill, a member of the Department of Family Medicine who has been a highly regarded teacher in that course, will be a taking on it’s leadership.

Chair, Progress and Promotions Committee

Dr. Fred Watkins
Dr. Richard van Wylick

For the past several years, Dr. Richard van Wylick has been providing exemplary service as chair of our Progress and Promotions Committee. In addition to very capably directing the complex activities of that group, he has developed a robust collection of policies and procedures to guide various aspects of student promotion, curricular management, student conduct and professionalism in our school. As Dr. Van Wylick has taken on other leadership roles, he has continued to direct P&P, but it is no longer either reasonable or fair to ask him to continue. Fortunately for us all, Dr. Fred Watkins, who has longstanding experience on the committee, consistently demonstrating excellent judgement and sensitivity, has agreed to take on the chairmanship.

Chair, Student Assessment Committee

Dr. Peter MacPherson

With Dr. Gibson’s move to the new position of Assistant Dean Curriculum, Dr. Peter MacPherson will replace her as Chair, Student Assessment Committee. Dr. McPherson completed a Master of Education degree at Memorial University during his Pediatrics residency with an academic and research focus on medical education. He brings his experience from across the curriculum, both pre-clerkship and clerkship, to his new duties as Chair.

New Course Directors

Dr. Brigid Nee

Dr. Greg Davies has been directing the Obstetrics and Gynecology clinical clerkship rotation for the past few years. During that time, Dr. Davies has built on the success established by that department. As Dr. Davies moves toward retirement, we welcome Dr. Brigid Nee to this new role.

Dr. Gillian MacLean

Over the past few years, the Pediatrics clinical rotation has benefited from the input of many members of that department, including Drs. Richard Van Wylick, Karen Grewal and, most recently, Dr. Peter McPherson. As Dr. McPherson concentrates his attention on the pre-clerkship course and new interests, we welcome Dr. Gillian MacLean.

These changes will provide much more corporate knowledge within the leadership group, since most individuals will have had experience directing multiple portfolios spanning different aspects of our curriculum. This should allow for much more effective and helpful sharing of experience and knowledge, and thus better problem solving and anticipation.

These changes are intended to begin with the new academic cycle that starts in September, but the various incoming and outcoming individuals are already developing specific transition plans to provide for smooth and effective turnover. 

I thank all those who’ve been filling these positions in past years for their dedication to our students and our school. Please join me in welcoming and supporting all those moving into these new challenges.

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The Rapture of the Raptors. Why do we care?

It shouldn’t matter that Kawhi Leonard decided to play basketball in Los Angeles instead of Toronto.

And yet it does.

The anticipation leading up to his decision was unprecedented. The media were in a frenzy. Speculation was rampant. Helicopters followed his every move. There were “spottings” of house sales and reported purchases of moving containers!

It shouldn’t matter that a dozen or so very highly-paid Americans won a championship for playing basketball while employed by a Toronto-based sporting corporation.

And yet it does.

The public celebration, the pride, the pure, unadulterated joy this brought to the people of Toronto and, indeed, all of Canada, went far beyond anything experienced by most living people, and rivalled the memory of celebrations triggered by the end of world wars.

ctvnews.ca

It shouldn’t matter whether Canadian-born hockey players fail to win the gold medal at a two week long international tournament played every four years.

And yet it does.

It’s viewed as a national shame and calamity, eliciting much hand-wringing, introspection, and calls for reviews, re-focusing on “priorities” and enhanced commitment.

There is, undeniably, something about sports and our identification with teams that simply transcends logic or rational thought. It goes far beyond our collective interest in politics, environmental concerns or the economy. 

Just this past week Lisa MacLeod, a provincial cabinet minister, was required to apologize for unleashing an obscenity-riddled diatribe upon the owner of a professional hockey team. In her tweet, she tries to justify the attack:

“Let me set the record straight, I gave @MelnykEugene some feedback at the Rolling Stones concert and I apologized to him for being so blunt. I have serious concerns about the state of our beloved Ottawa Senators!”

Beloved? Really?

One of my favourite history writers, Pulitzer Prize winner Doris Kearns Goodwin, writes in her memoir “Wait Till Next Year” of her “childhood love” of the Brooklyn Dodgers and her “desolation when they moved to California”.

And I certainly can’t claim to be immune. I find the current mediocrity of the Blue Jays a personal offense and, for the past 50+ years, have gone into an annual spring funk when the Maple Leafs make their inevitable and ignominious exit from the playoffs.

Why do I care? Why do any of us care?

Certainly, there’s no question that the passion is real. For those who need convincing, I would refer them to a 2008 article by Ute Wilbert-Lampen and colleagues (NEJM 2008;358:475-483). They looked at the incidence of cardiac events in the greater Munich area during the 2006 World Cup of soccer. On days when the German team was playing, the incidence was 2.66 higher than during control periods (p<0.001). Men were more likely to be affected (3.26 times higher), but women were affected as well (1.82 times higher). There were clear spikes on days, and times, that the German team played, as illustrated below, points 5 and 6 being days Germany was playing the most critical games (Game 6 being their loss to eventual champion Italy, I might point out):

from Wilbert-Lampen etal. NEJM 2008; 358: 475.

Need more convincing? Consider a study carried out by Paul Bernhardt as part of his doctoral project. He measured testosterone levels in male spectators of sporting events, specifically basketball games at Georgia State University (Physiology and Behaviour 1998;65:59-62). He found that levels rose in a pattern similar to that of the players during the game, and decreased in the fans of the losing team. It seems that rabid fans are very much “in the game”. 

But what’s driving all this?

Psychologists and sociologists have explored the topic. Theories abound. Some believe team fanaticism allows for permission to step out of everyday lives and take on a different, more outgoing persona. The term “deindividuation” has been bandied about, which seems to mean that you can behave in a crowd in a way you never would alone. There’s a certain connection that occurs between fans of the same team that appears to promote self-esteem and carries over to everyday life. Terms like “relationship” and “bonding” have been applied to what happens between fans and their team.

Daniel Murray is a psychology professor at Murray State University. In his book “Sport Fans: The Psychology and Social Impact of Fandom”, he presents a combination of research and theory and makes a case that fandom promotes a sense of belonging, and overall psychological health. It appears to happen even if your team is unsuccessful – witness the Chicago Cubs whose fan base remained loyal despite not having won the World Series for 108 years or, dare I say it, our long-suffering Maple Leaf fans.

The term “Basking in Reflected Glory” (BIRG) has been used to describe the tendency to identify with successful teams and is ascribed to Professor Robert Cialdini who observed that the usage of team apparel in high school and college students varied in concert with the success of school teams. No surprise, I’m sure, to vendors of Raptors jerseys these past few weeks.

There are certainly positives to all this. In addition to transcending logic, sports fandom also appears to transcend issues of race and economic disparity. Sports appear to have a power to unite our society in a way that goes far beyond anything that can be achieved through any public policy. The Raptor players, taking in the adoring multitudes that turned out to celebrate their recent success, commented on the visible diversity of the crowds, something they’d not seen previously.

In the end, I would suggest that all this is about something much more fundamental. We have a basic human need to belong, to connect with others, to be part of something greater than ourselves. We can call it family, community, religion, social group, tribe, any or all of the above. We need to belong. We may wander, but will always identify with “home” and, to some extent, yearn to return. Allegiance with a particular team seems, to some extent, to address that need. For some of us, it’s ingrained in childhood and difficult to expunge (as much as we might like to). For others it’s acquired along the way, but no less real.

Returning to the topic at hand, what are we to make of Mr. Leonard’s recent departure? Certainly, it wasn’t motivated by monetary considerations or need to find a winning team, since he’d already achieved both those goals. In the end, his motivation seems to be something that the millions of fans who wished him to remain in Canada can easily understand.  Having been born and raised in Southern California, he didn’t so much reject Toronto as he chose to return to his own home, his own roots. Not many professional athletes have that option, and we should not begrudge him the choice. How many of us, given the same circumstances, would do the same? In the end, it’s about home It’s about belonging.

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Can admissions committees measure adversity? Should they?

“If you can’t measure it, it doesn’t exist.”

This was the mantra of a former mentor and research supervisor with whom I had the opportunity to work during my fellowship. In the early days of Echocardiography we, and many others, were working hard to bring some degree of quantitative rigour and credibility to a developing imaging modality which, at that time, consisted of rather blurry black and white recordings of the beating heart on a small screen. The images could be photographed and even videotaped. As such, they were remarkably informative to the person obtaining the image and treating the patient under observation, but the technology provided no inherent measurements and could not be transmitted to referring physicians. If Echocardiography was to have sustaining value as a service to the larger medical community, most contended, it must yield measurements that would differentiate normal structure and function from the pathologic. Hence countless postulates, projects, manuscripts, publications and fellowships, including mine.

In most cases these efforts to derive measurements and “normal ranges” from moving images have been of great clinical value and has advanced patient care. However there have been, and continue to be, numerous instances where over-zealous attempts to quantitate have caused misinterpretation, often due to over-simplification of a complex image or set of images that has much more value to the observer than any static measurement can convey. Trying to compress the meaning of an image into a set of simple measures will always have inherent limitations. What numeric value could one apply to da Vinci’s Mona Lisa that would convey even a fraction of what the human eye and mind can perceive in a few seconds of observation?

Recently, considerable controversy has arisen in the United States as a result of attempts to incorporate measurements of adversity into the college admission process. The Scholastic Aptitude Test (SAT) is undertaken by American high school graduates and is a key component of their application to colleges and universities. It is widely considered to be a primary driver of admission decisions in an environment where admission to “top tier” universities is highly competitive and, recently, the subject of criminal prosecution in the United States.  

This new score, dubbed the “Adversity Index” is a composite of 15 factors, including measures of crime rate and poverty in the neighbourhood in which the applicant has been raised and an assessment of the “quality” of the high school attended.

https://www.wsj.com/articles/sat-to-give-students-adversity-score-to-capture-social-and-economic-background-11557999000

It provides a score scaled between 1 and 100, with higher scores indicating greater degrees of “disadvantage”. The Adversity Index is not used to adjust SAT test scores in any way, but provided separately to admission committees, presumably to “contextualize” the scores as they see fit.

The intent appears to be to level the admissions playing field that most agree favours applicants from wealthier backgrounds who can attend more academically rigourous high schools and benefit from more time and support for academics. It is also felt to identify students who have overcome personal adversity and demonstrated commitment and resourcefulness in order to achieve their success. The New York Times article cited above quotes Mr. David Coleman, CEO of the College Board:

“Merit is all about resourcefulness. This is about finding young people who do a great deal with what they’ve been given. It helps colleges see students who may not have scored as high, but when you look at the environment that they have emerged from, it is amazing.”

As one might imagine, not all agree. American College Testing (ACT) provides an alternative admission test for college applicants. Its CEO, Mr. Marten Roorda states the counter-argument in a recent blog post:

 “The algorithm and research behind this adversity score have not been published. It is basically a black box. Any composite score and any measurement in general requires transparency; students, teachers and admissions officers have the right to know. Now we can’t review the validity and the fairness of the score. And even if that changes, there is also an issue with the reliability of the measure, since many of the 15 variables come from an unchecked source — for example, when they are self-reported by the student.”

http://leadershipblog.act.org/2019/05/adversity-score-college-boards.html

All this comes about at a time when college and university admission processes are under siege as a result of a number of highly publicized reports of inappropriate influence exerted by wealthy and influential parents.

https://www.cbsnews.com/news/college-admissions-scandal-bribery-cheating-today-felicity-huffman-arrested-fbi-2019-03-12/
https://www.nytimes.com/news-event/college-admissions-scandal

The repercussions and resulting enquiries have uncovered dubious practices, even in venerable institutions.




https://www.nytimes.com/2018/10/19/us/harvard-admissions-affirmative-action.html?module=inline

And so, what are we to make of all this? Does any of this translate to Canada, and specifically to medical school admission, certainly among the most competitive choices available to young people? A few key questions and postulated answers. (Please note: following are the opinions of the author, and the author alone).

Q. Does wealth and privilege facilitate admission?

A. Almost certainly yes. For further discussion see previous blogs:

Does every Canadian have equal opportunity to pursue a Medical Education?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1165&action=edit

Medical School Admissions: Unintended Consequences

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=407&action=edit

Medical Student Debt: A problem, or shrewd investment?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1807&action=edit

Q. Do we wish to admit a more diverse student population, including students from traditionally socioeconomically disadvantaged groups?

A. Yes. All medical schools have engaged this challenge in various ways. At Queen’s both the medical school and university have made clear statements to this effect.

https://www.queensu.ca/universityrelations/equity
https://meds.queensu.ca/academics/undergraduate/policies-committees/diversity-equity-statement

Q. Do adversity experiences build qualities desirable in medical school applicants?

A. They may, but not necessarily. Simply experiencing adversity is not sufficient. That experience must have resulted in a valuable learning experience that has contributed to the applicants ability to choose and undertake a career in medicine. In fact we must recognize that adversity experiences, unfortunately, have the potential to be highly damaging.

Q. How does “disadvantage” equate to “adversity”.

A. They correlate, but not precisely. To use an example from the cardiology world, sedate hypercholesterolemic people are at higher risk of developing premature ischemic heart disease, but they may not, and many active folks with normal cholesterol levels will. This is the nature of a “risk factor”. Lower socioeconomic status certainly puts one at risk for greater life adversity, probably at a linear fashion where poverty levels virtually guarantees adversity. Conversely, socioeconomic stability certainly provides no immunity from adversity experiences.   

Q. Will an Adversity Index developed from compiled demographic and self-reported data provide a valid reflection of a student’s development and preparation for a career in medicine?

A. In and of itself, probably not. The information upon which it is based is inherently flawed, imprecise, and subject to manipulation.

Q. Will an examination of personal adversity and its impact on personal growth be helpful?

A. Yes. The study and practice of medicine requires commitment and resilience, both of which can be developed by adversity experiences successfully engaged.

And so, examining disadvantage is essential to addressing diversity goals, but Admissions Committees must develop robust methods to  determine if adversity has been experienced, and what impact has resulted from those experiences. A numerical index such as that developed by SAT may provide a useful starting point, but is no more revealing than is a linear dimension obtained from recordings of the beating human heart.

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